OBJECTIVES: CA 15-3 and CEA are tumor markers used in routine clinical care for breast cancer and colorectal cancer, among others. Current measurement procedures (MP) for these tumor markers are considered to be insufficiently harmonized. This study investigated the achievable harmonization for CA 15-3 and CEA by using an in silico simulation of external quality assessment (EQA) data from multiple EQA programs using patient-pool based samples. METHODS: CA 15-3 and CEA data from SKML (2021), UK NEQAS (2020-2021) and KEQAS (2020-2021) were used. A harmonization protocol was defined in which MPs that were considered equivalent were used to value assign EQA samples, and recalibration was only required if the MP had a bias of >5 % with value assigned EQA. Harmonization status was assessed by determining the mean level of agreement and residual variation by CV (%). RESULTS: Only MPs from Abbott, Beckman, Roche and Siemens were available in all EQA programs. For CA 15-3, recalibration was proposed for Beckman MP only and for CEA, recalibration was proposed for Siemens MP only. When the harmonization procedures were applied, for CA 15-3 the pre-harmonization mean bias range per MP was reduced from -29.28 to 9.86 %, into -0.09-0.12 % after harmonization. For CEA, the mean bias range per MP was reduced from -23.78 to 2.00 % pre-harmonization to -3.13-1.42 % post-harmonization. CONCLUSIONS: The present study suggests that a significant improvement in the harmonization status of CA 15-3 and CEA may be achieved by recalibration of a limited number of MPs.

Background: Cancer-associated venous thromboembolism (CA-VTE) represents a major cause of morbidity and mortality in patients with cancer. Despite poor outcomes, there is an ongoing knowledge gap in epidemiologic data related to this association. Objectives: To compare venous thromboembolism (VTE) characteristics, risk factors, and outcomes between patients with and without active cancer in a racially diverse population. Methods: Our surveillance project occurred at the 3 hospitals in Durham County, North Carolina, from April 2012 through March 2014. Electronic and manual methods were used to identify unique Durham County residents with VTE. Results: We identified 987 patients with VTE during the surveillance period. Of these, 189 patients had active cancer at the time of their VTE event. Patients with CA-VTE were older (median age: 69 years vs 60 years, P < .0001) and had a lower body mass index (median body mass index: 26.0 kg/m2 vs 28.4 kg/m2, P = .0001) than noncancer patients. The most common cancers in our cohort were gastrointestinal, breast, genitourinary, and lung. The proportion of VTE cases with pulmonary embolism (PE) was greater in the cancer cohort compared with that in the noncancer cohort (58.2% vs 44.0%, P = .0004). Overall survival was lower in the CA-VTE group than in patients without cancer (P < .0001). Black patients with CA-VTE had lower proportion of PE (52.3% vs 67.1%, P = .05) but had decreased survival (P < .0003) in comparison with White patients. Conclusion: Future studies may be needed to continue to evaluate local and national VTE data to improve VTE prevention strategies and CA-VTE outcomes. © 2024 The Authors

BACKGROUND: The harmonization status of most tumor markers (TMs) is unknown. We report a feasibility study performed to determine whether external quality assessment (EQA) programs can be used to obtain insights into the current harmonization status of the tumor markers α-fetoprotein (AFP), prostate specific antigen (PSA), carcinoembryonic antigen (CEA), cancer antigen (CA)125, CA15-3 and CA19-9. METHODS: EQA sample results provided by 6 EQA providers (INSTAND [Germany], Korean Association of External Quality Assessment Service [KEQAS, South Korea], National Center for Clinical Laboratories [NCCL, China], United Kingdom National External Quality Assessment Service [UK NEQAS, United Kingdom], Stichting Kwaliteitsbewaking Medische Laboratoriumdiagnostiek [SKML, the Netherlands], and the Royal College of Pathologists of Australasia Quality Assurance Programs [RCPAQAP, Australia]) between 2020 and 2021 were used. The consensus means, calculated from the measurement procedures present in all EQA programs (Abbott Alinity, Beckman Coulter DxI, Roche Cobas, and Siemens Atellica), was used as reference values. Per measurement procedure, the relative difference between consensus mean for each EQA sample and the mean of all patient-pool-based EQA samples were calculated and compared to minimum, desirable, and optimal allowable bias criteria based on biological variation. RESULTS: Between 19040 (CA15-3) and 25398 (PSA) individual results and 56 (PSA) to 76 (AFP) unique EQA samples were included in the final analysis. The mean differences with the consensus mean of patient-pool-based EQA samples for all measurement procedures were within the optimum bias criterion for AFP, the desirable bias for PSA, and the minimum bias criterion for CEA. However, CEA results <8 µg/L exceeded the minimum bias criterion. For CA125, CA15-3, and CA19-9, the harmonization status was outside the minimum bias criterion, with systematic differences identified. CONCLUSIONS: This study provides relevant information about the current harmonization status of 6 tumor markers. A pilot harmonization investigation for CEA, CA125, CA15-3, and CA19-9 would be desirable.

INTRODUCTION: In 2020, the COVID-19 pandemic led to significant declines in cancer screening, including among women served by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). This study examined the spatial association between state-based COVID-19 test percent positivity and proportional change in NBCCEDP screening volume. METHODS: Using the COVID-19 Diagnostic Laboratory Testing dataset, we calculated state-based monthly COVID-19 test percent positivity from July through December 2020 and categorized rates into low, medium, and high groups. We used data from 48 NBCCEDP state awardees to calculate the state-based monthly proportional change in screening volume and compared data for July-December 2020 with the previous 5-year average for those months. We categorized changes in screening volume into large decrease, medium decrease, and minimal change and created maps of the associations between variable subgroups by using bivariate mapping in QGIS. RESULTS: Bivariate relationships between COVID-19 test percent positivity and proportional change in cancer screening volume varied over time and geography. In 5 of 6 months, 4 states had high COVID-19 test percent positivity and minimal change in breast or cervical cancer screening volume; 2 states had high COVID-19 test percent positivity and minimal change in breast and cervical cancer screening volume. CONCLUSION: Some states maintained pre-COVID-19 screening volumes despite high COVID-19 test percent positivity. Follow-up research will be conducted to determine how these states differ from those with consistent decreases in screening volume and identify factors that may have contributed to differences. This information could be useful for planning to maximize NBCCEDP awardees' ability to maintain screening volume during future public health emergencies.

BACKGROUND: Venous thromboembolism (VTE) affects approximately 1-2 individuals per 1000 annually and is associated with an increased risk for pulmonary hypertension, postthrombotic syndrome, and recurrent VTE. OBJECTIVE: To determine risk factors, incidence, treatments, and outcomes of VTE through a 2-year surveillance program initiated in Durham County, North Carolina (population approximately 280,000 at time of study). PATIENTS/METHODS: We performed a retrospective analysis of data actively collected from three hospitals in Durham County during the surveillance period. RESULTS: A total of 987 patients were diagnosed with VTE, for an annual rate of 1.76 per 1000 individuals. Hospital-associated VTE occurred in 167 hospitalized patients (16.9%) and 271 outpatients who were hospitalized within 90 days of diagnosis (27.5%). Annual incidence was 1.98 per 1000 Black individuals compared to 1.25 per 1000 White individuals (p < 0.0001), and Black individuals with VTE were younger than White individuals (p < 0.0001). Common risk factors included active cancer, prolonged immobility, and obesity, and approximately half were still taking anticoagulant therapy 1 year later. A total of 224 patients died by 1 year (28.5% of patients for whom outcomes could be confirmed), and Black patients were more likely to have recurrent VTE than White patients during the first 6 months following initial presentation (9.4% vs. 4.1%, p = 0.01). CONCLUSIONS: Ongoing surveillance provides an effective strategy to identify patients with VTE and monitor treatment and outcomes. We demonstrated that hospital-associated VTE continues to be a major contributor to the burden of VTE and confirmed the higher incidence of VTE in Black compared to White individuals.

BACKGROUND: Data on the population-based incidence of cancer-associated venous thromboembolism (VTE) from racially diverse populations are limited. OBJECTIVE: To evaluate the incidence and burden of cancer-associated VTE, including demographic and racial subgroups in the general population of Oklahoma County-which closely mirrors the United States. DESIGN: Population-based prospective study. SETTING: We conducted surveillance of VTE at tertiary care facilities and outpatient clinics in Oklahoma County, Oklahoma from 2012-2014. Surveillance included reviewing all imaging reports used to diagnose VTE and identifying VTE events from hospital discharge data and death certificates. Cancer status was determined by linkage to the Oklahoma Central Cancer Registry. MEASUREMENTS: We used Poisson regression to calculate crude and age-adjusted incidences of cancer-associated VTE per 100,000 general population per year, with 95% confidence intervals (95% CI). RESULTS: The age-adjusted incidence (95% CI) of cancer-associated VTE among adults age 18 was 70.0 (65.1-75.3). The age-adjusted incidence rates (95% CI) were 85.9 (72.7-101.6) for non-Hispanic Black persons, 79.5 (13.2-86.5) for non-Hispanic White persons, 18.8 (8.9-39.4) for Native American persons, 15.6 (7.0-34.8) for Asian/Pacific Islander persons, and 15.2 (9.2-25.1) for Hispanic persons. Recurrent VTE up to 2years after the initial diagnosis occurred in 38 of 304 patients (12.5%) with active cancer and in 34 of 424 patients (8.0%) with a history of cancer >6 months previously. CONCLUSION: Age-adjusted incidence rates of cancer-associated VTE vary substantially by race and ethnicity. The relatively high incidences of first VTE and of recurrence warrant further assessment of strategies to prevent VTE among cancer patients.

BACKGROUND:  Contemporary incidence data for venous thromboembolism (VTE) from racially diverse populations are limited. The racial distribution of Oklahoma County closely mirrors that of the United States. OBJECTIVE:  To evaluate VTE incidence and mortality, including demographic and racial subgroups. DESIGN:  Population-based prospective study. SETTING:  We conducted VTE surveillance at all relevant tertiary care facilities and outpatient clinics in Oklahoma County, Oklahoma during 2012 to 2014, using both active and passive methods. Active surveillance involved reviewing all imaging reports used to diagnose VTE. Passive surveillance entailed identifying VTE events from hospital discharge data and death certificate records. MEASUREMENTS:  We used Poisson regression to calculate crude, age-stratified, and age-adjusted incidence and mortality rates per 1,000 population per year and 95% confidence intervals (CIs). RESULTS:  The incidence rate of all VTE was 3.02 (2.92-3.12) for those age ≥18 years and 0.05 (0.04-0.08) for those <18 years. The age-adjusted incidence rates of all VTE, deep vein thrombosis, and pulmonary embolism were 2.47 (95% CI: 2.39-2.55), 1.47 (1.41-1.54), and 0.99 (0.93-1.04), respectively. The age-adjusted VTE incidence and the 30-day mortality rates, respectively, were 0.63 and 0.121 for Asians/Pacific Islanders, 3.25 and 0.355 for blacks, 0.67 and 0.111 for Hispanics, 1.25 and 0.195 for Native Americans, and 2.71 and 0.396 for whites. CONCLUSION:  The age-adjusted VTE incidence and mortality rates vary substantially by race. The incidence of three per 1,000 adults per year indicates an important disease burden, and is informative of the burden in the U.S.

Wearing masks is a CDC-recommended* approach to reduce the spread of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), by reducing the spread of respiratory droplets into the air when a person coughs, sneezes, or talks and by reducing the inhalation of these droplets by the wearer. On July 2, 2020, the governor of Kansas issued an executive order(†) (state mandate), effective July 3, requiring masks or other face coverings in public spaces. CDC and the Kansas Department of Health and Environment analyzed trends in county-level COVID-19 incidence before (June 1-July 2) and after (July 3-August 23) the governor's executive order among counties that ultimately had a mask mandate in place and those that did not. As of August 11, 24 of Kansas's 105 counties did not opt out of the state mandate(§) or adopted their own mask mandate shortly before or after the state mandate was issued; 81 counties opted out of the state mandate, as permitted by state law, and did not adopt their own mask mandate. After the governor's executive order, COVID-19 incidence (calculated as the 7-day rolling average number of new daily cases per 100,000 population) decreased (mean decrease of 0.08 cases per 100,000 per day; net decrease of 6%) among counties with a mask mandate (mandated counties) but continued to increase (mean increase of 0.11 cases per 100,000 per day; net increase of 100%) among counties without a mask mandate (nonmandated counties). The decrease in cases among mandated counties and the continued increase in cases in nonmandated counties adds to the evidence supporting the importance of wearing masks and implementing policies requiring their use to mitigate the spread of SARS-CoV-2 (1-6). Community-level mitigation strategies emphasizing wearing masks, maintaining physical distance, staying at home when ill, and enhancing hygiene practices can help reduce transmission of SARS-CoV-2.

BACKGROUND: Systematic surveillance for venous thromboembolism (VTE) in the United States has been recommended by several organizations. Despite adoption of electronic medical records (EMRs) by most health care providers and facilities, however, systematic surveillance for VTE is not available. OBJECTIVES: This article develops a comprehensive, population-based surveillance strategy for VTE in a defined geographical region. METHODS: The primary surveillance strategy combined computerized searches of the EMR with a manual review of imaging data at the Duke University Health System in Durham County, North Carolina, United States. Different strategies of searching the EMR were explored. Consolidation of results with autopsy reports (nonsearchable in the EMR) and with results from the Durham Veterans' Administration Medical Center was performed to provide a comprehensive report of new VTE from the defined region over a 2-year timeframe. RESULTS: Monthly searches of the primary EMR missed a significant number of patients with new VTE who were identified by a separate manual search of radiology records, apparently related to delays in data entry and coding into the EMR. Comprehensive searches incorporating a location-restricted strategy were incomplete due to the assigned residence reflecting the current address and not the address at the time of event. The most comprehensive strategy omitted the geographic restriction step and identified all patients with VTE followed by manual review of individual records to remove incorrect entries (e.g., outside the surveillance time period or geographic location; no evidence for VTE). Consolidation of results from the EMR searches with results from autopsy reports and the separate facility identified additional patients not diagnosed within the Duke system. CONCLUSION: We identified several challenges with implementing a comprehensive VTE surveillance program that could limit accuracy of the results. Improved electronic strategies are needed to cross-reference patients across multiple health systems and to minimize the need for manual review and confirmation of results.

Carpal tunnel syndrome (CTS) occurs when the median nerve becomes compressed as it passes through the wrist within the carpal tunnel, resulting in pain, tingling, weakness, or numbness in the hand or the wrist. Occupational risk factors for CTS include engaging in work activities that require forceful, repetitive tasks, prolonged use of the hands or wrists in an awkward posture, or vibration (1). To assess trends and identify high-risk industries and occupations for CTS, the California Department of Public Health (CDPH) analyzed California workers' compensation claims for CTS by industry (2007-2014) and occupation (2014) and calculated rates per full-time equivalent (FTE) worker. During 2007-2014, a total of 139,336 CTS cases were reported (incidence = 6.3 cases per 10,000 FTE) in California workers; the rate among women (8.2) was 3.3 times higher than that among men (2.5). Industries with the highest rates of CTS were textile, fabric finishing, and coating mills (44.9), apparel accessories and other apparel manufacturing (43.1), and animal slaughtering and processing (39.8). Industries with high rates of CTS should consider implementing intervention measures, including ergonomic evaluations and development of tools and instruments that require less repetition and force and that correct awkward postures.

Total release foggers (TRFs) (also known as "bug bombs") are pesticide products often used indoors to kill insects. After an earlier report found that TRFs pose a risk for acute illness (1), the Environmental Protection Agency required improved labels on TRFs manufactured after September 2012 (2). To examine the early impact of relabeling, the magnitude and characteristics of acute TRF-related illness were evaluated for the period 2007-2015. A total of 3,222 TRF-related illnesses were identified in 10 participating states, based on three data sources: Sentinel Event Notification System for Occupational Risk-Pesticides (SENSOR) programs, the California Department of Pesticide Regulation (CDPR) program, and poison control centers (PCCs) in Florida, Texas, and Washington. No statistically significant decline in the overall TRF-illness incidence rate was found. Failure to vacate treated premises during application was the most commonly reported cause of exposure. To reduce TRF-related illness, integrated pest management strategies (3) need to be adopted, as well as better communication about the hazards and proper uses of TRFs. Redesigning TRFs to prevent sudden, unexpected activation might also be useful.

INTRODUCTION: The United States federally mandated reporting of venous thromboembolism (VTE), defined by Agency for Healthcare Research & Quality Patient Safety Indicator 12 (AHRQ PSI-12), is based on administrative data, the accuracy of which has not been consistently demonstrated. We used IDEAL-X, a novel information extraction software system, to identify VTE from electronic medical records and evaluated its accuracy. METHODS: Medical records for 13,248 patients admitted to an orthopedic specialty hospital from 2009 to 2014 were reviewed. Patient encounters were defined as a hospital admission where both surgery (of the spine, hip, or knee) and a radiology diagnostic study that could detect VTE was performed. Radiology reports were both manually reviewed by a physician and analyzed by IDEAL-X. RESULTS: Among 2083 radiology reports, IDEAL-X correctly identified 176/181 VTE events, achieving a sensitivity of 97.2% [95% confidence interval (CI), 93.7%-99.1%] and specificity of 99.3% (95% CI, 98.9%-99.7%) when compared with manual review. Among 422 surgical encounters with diagnostic radiographic studies for VTE, IDEAL-X correctly identified 41 of 42 VTE events, achieving a sensitivity of 97.6% (95% CI, 87.4%-99.6%) and specificity of 99.8% (95% CI, 98.7%-100.0%). The performance surpassed that of AHRQ PSI-12, which had a sensitivity of 92.9% (95% CI, 80.5%-98.4%) and specificity of 92.9% (95% CI, 89.8%-95.3%), though only the difference in specificity was statistically significant (P<0.01). CONCLUSION: IDEAL-X, a novel information extraction software system, identified VTE from radiology reports with high accuracy, with specificity surpassing AHRQ PSI-12. IDEAL-X could potentially improve detection and surveillance of many medical conditions from free text of electronic medical records.

Venous thromboembolism (VTE), blood clots occurring as deep vein thrombosis, pulmonary embolism, or both, is an important and growing public health issue. The precise number of people affected by VTE is unknown; however, estimates suggest that up to 900,000 events resulting in as many as 100,000 premature deaths occur in the United States yearly with healthcare costs as high as $10 billion.1–3 Although anyone can develop VTE, research has shown that half of VTE events occurring in the outpatient setting are directly linked to a recent hospitalization or surgery.4 In patients with cancer, VTE is a leading cause of death after the cancer itself.5,6 Fortunately, many of these healthcare-associated VTE (HA-VTE) cases can be prevented. Recent analyses have shown that as many as 70% of HA-VTE cases are preventable through appropriate prophylaxis,7–9 yet reports suggest that fewer than half of hospital patients receive VTE prophylaxis in accordance with accepted evidence-based guidelines.10 Appropriate prevention of HA-VTE can result in a significant reduction in overall VTE occurrence, thereby decreasing healthcare burden and unnecessary deaths. | In November 2015, the Centers for Disease Control and Prevention (CDC) released the Healthcare-Associated VTE Prevention Challenge (http://www.cdc.gov/ncbddd/dvt/ha-vte-challenge.html) to identify, highlight, and reward hospitals, managed care organizations, and hospital networks that implemented innovative, effective, and sustainable strategies to prevent HA-VTE.

Commutability of External Quality Assessment (EQA)1 materials is a key requirement for their use in accuracy-based EQA surveys (1–3). In a recent paper, Korzun et al. (4) evaluated commutability of 4 frozen pools for measurements of direct HDL cholesterol (HDLC) and LDL cholesterol (LDLC). These pools were used in the CDC’s Lipid Standardization Program to assess accuracy of direct HDLC measurements only (4). | Among the results presented using the medical requirement acceptance criteria for bias (4% for LDLC and 5% for HDLC), the authors found that 1 of the 4 frozen pools was commutable for most of the HDLC methods, whereas none were commutable for LDLC methods. The authors concluded that frozen pools prepared according to the CLSI C37 protocol may not always be commutable and especially for direct LDLC assays. | In 2013, Laboratoire national de métrologie et d’essais (LNE) organized a similar study to assess commutability of 5 freshly prepared frozen serum pools prepared according to the CLSI C37-A protocol for HDLC and LDLC. The pools were shipped frozen and analyzed along with 20–25 fresh clinical specimens by 31 medical laboratories operating HDLC and LDLC routine methods on the most popular clinical chemistry analyzers: Roche Cobas, Siemens Vista, Abbott Architect, Ortho CD Vitros, Beckman DxC, Beckman AU, Roche Modular, and Thermo Konelab.

CDC's National Institute for Occupational Safety and Health (NIOSH) collects data on acute pesticide-related illness and injury reported by 12 states (California, Florida, Iowa, Louisiana, Michigan, Nebraska, North Carolina, New Mexico, New York, Oregon, Texas, and Washington). This report summarizes the data on illnesses and injuries arising from occupational exposure to conventional pesticides from 2007 through 2011. This report is a part of the Summary of Notifiable Noninfectious Conditions and Disease Outbreaks - United States, which encompasses various surveillance years but is being published in 2016. The Summary of Notifiable Noninfectious Conditions and Disease Outbreaks appears in the same volume of MMWR as the annual Summary of Notifiable Infectious Diseases. In a separate report, data on illnesses and injuries from nonoccupational exposure to pesticides during 2007-2011 are summarized.

BACKGROUND: Paraquat and diquat are among the most commonly used herbicides in the world. OBJECTIVES: Determine the magnitude, characteristics, and root causes for acute paraquat- and diquat-related illnesses in the US. METHODS: Illnesses associated with paraquat or diquat exposure occurring from 1998 through 2011 were identified from the Sentinel Event Notification System for Occupational Risks (SENSOR)-Pesticides Program, the California Department of Pesticide Regulation (CDPR) Pesticide Illness Surveillance Program (PISP), and the Incident Data System (IDS). Cases identified by the National Poison Data System (NPDS) were reviewed for the years 1998-2003 and 2006-2013. RESULTS: A total of 300 paraquat- and 144 diquat-related acute illnesses were identified by SENSOR, PISP, and IDS. NPDS identified 693 paraquat- and 2128 diquat-related acute illnesses. In SENSOR/PISP/IDS, illnesses were commonly low severity (paraquat=41%; diquat=81%); however, SENSOR/PISP/IDS identified 24 deaths caused by paraquat and 5 deaths associated with diquat. Nineteen paraquat-related deaths were due to ingestion, seven of which were unintentional, often due to improper storage in beverage bottles. In SENSOR/PISP/IDS, paraquat and diquat-related acute illnesses were work-related in 68% (n=203) and 29% (n=42) of cases, respectively. When herbicide application site was known, the vast majority of acute paraquat-related illnesses (81%) arose from agricultural applications. Common root causes of illness were failure to use adequate personal protective equipment (PPE), application equipment failure, and spill/splash of herbicide. CONCLUSIONS: Although the magnitude of acute paraquat/diquat-related illnesses was relatively low, several fatalities were identified. Many illnesses could be prevented through stricter compliance with label requirements (e.g. ensuring proper herbicide storage and PPE use), and through enhanced training of certified applicators.

CDC's National Institute for Occupational Safety and Health (NIOSH) collects data on acute pesticide-related illnesses and injuries reported by 11 states (California, Florida, Iowa, Louisiana, Michigan, North Carolina, New Mexico [2007–2008 only], New York, Oregon, Texas, and Washington). This report summarizes data on illnesses and injuries arising from occupational exposure to conventional pesticides during 2007–2010. This report is a part of the first-ever Summary of Notifiable Noninfectious Conditions and Disease Outbreaks, which encompasses various surveillance years but is being published in 2015 (1). The Summary of Notifiable Noninfectious Conditions and Disease Outbreaks appears in the same volume of MMWR as the annual Summary of Notifiable Infectious Diseases (2). | Background | Pesticides are substances or mixtures of substances intended to prevent, destroy, repel, or mitigate pests (e.g., insects, rodents, fungi, and weeds). In 2007, the year with the most currently available data, an estimated 2.1 billion pounds of conventional pesticides were used in the United States (3), which represents approximately 22% of the entire worldwide use of these pesticides. Conventional pesticides include insecticides, herbicides, fungicides, and fumigants and exclude chlorine, hypochlorites, and biocides. | The toxicity of pesticides continues to raise public concern and is the focus of much media attention. The benefits of pesticides are well recognized and primarily include their role in protecting the food supply and in controlling disease vectors (4). However, no form of pest control is perfectly safe. Tracking the associated health effects of pesticides can help ensure that no pesticides pose an unreasonable burden (5). As such, public health surveillance of acute pesticide-related illness and injury serves a vital societal role by assessing the magnitude and characteristics of this condition. Surveillance of acute pesticide-related illness and injury has been endorsed by several professional organizations and federal agencies including the American Medical Association (6), the Council of State and Territorial Epidemiologists (7), NIOSH (8), and the U.S. Government Accountability Office (9). To address the need for public health surveillance of acute pesticide-related illness and injury, NIOSH established such a surveillance program in 1987. | Pesticide products must pass an extensive battery of testing prior to being registered by the U.S. Environmental Protection Agency (EPA). This testing forms the basis for the human health and environmental risk assessments conducted by EPA that guide identification of the conditions under which a pesticide can be used. These conditions of use are reflected in pesticide product labeling. Compliance with these use conditions are expected to prevent unreasonable adverse effects to human health and the environment. To verify the real-world effectiveness of pesticide product labeling in preventing adverse human health effects, findings from acute pesticide-related illness and injury surveillance systems are reviewed. These surveillance data assist EPA to determine whether labeling is effective or if labeling improvements are needed. When adverse health effects occur despite adherence to label instructions, and if EPA determines the magnitude to be unreasonable, EPA requires that interventions be instituted that involve changing pesticide use practices and/or modifying regulatory measures (10). Acute pesticide-related illness and injury also can occur because of a lack of compliance with existing pesticide regulations. The appropriate interventions for these cases include enhanced education and enforcement.

BACKGROUND: The Alere point-of-care (POC) Pima CD4 analyzer allows for decentralized testing and expansion to testing antiretroviral therapy (ART) eligibility. A consortium conducted a pooled multi-data technical performance analysis of the Pima CD4. METHODS: Primary data (11,803 paired observations) comprised 22 independent studies between 2009-2012 from the Caribbean, Asia, Sub-Saharan Africa, USA and Europe, using 6 laboratory-based reference technologies. Data were analyzed as categorical (including binary) and numerical (absolute) observations using a bivariate and/or univariate random effects model when appropriate. RESULTS: At a median reference CD4 of 383 cells/mul the mean Pima CD4 bias is -23 cells/mul (average bias across all CD4 ranges is 10 % for venous and 15 % for capillary testing). Sensitivity of the Pima CD4 is 93 % (95 % confidence interval [CI] 91.4 % - 94.9 %) at 350 cells/mul and 96 % (CI 95.2 % - 96.9 %) at 500 cells/mul, with no significant difference between venous and capillary testing. Sensitivity reduced to 86 % (CI 82 % - 89 %) at 100 cells/mul (for Cryptococcal antigen (CrAg) screening), with a significant difference between venous (88 %, CI: 85 % - 91 %) and capillary (79 %, CI: 73 % - 84 %) testing. Total CD4 misclassification is 2.3 % cases at 100 cells/mul, 11.0 % at 350 cells/mul and 9.5 % at 500 cells/mul, due to higher false positive rates which resulted in more patients identified for treatment. This increased by 1.2 %, 2.8 % and 1.8 %, respectively, for capillary testing. There was no difference in Pima CD4 misclassification between the meta-analysis data and a population subset of HIV+ ART naive individuals, nor in misclassification among operator cadres. The Pima CD4 was most similar to Beckman Coulter PanLeucogated CD4, Becton Dickinson FACSCalibur and FACSCount, and less similar to Partec CyFlow reference technologies. CONCLUSIONS: The Pima CD4 may be recommended using venous-derived specimens for screening (100 cells/mul) for reflex CrAg screening and for HIV ART eligibility at 350 cells/mul and 500 cells/mul thresholds using both capillary and venous derived specimens. These meta-analysis findings add to the knowledge of acceptance criteria of the Pima CD4 and future POC tests, but implementation and impact will require full costing analysis.

Estimates of venous thromboembolism (VTE) incidence in the United States are limited by lack of a national surveillance system. We implemented a population-based surveillance system in Oklahoma County, OK, for April 1, 2012 to March 31, 2014, to estimate the incidences of first-time and recurrent VTE events, VTE-related mortality, and the proportion of case patients with provoked versus unprovoked VTE. The Commissioner of Health made VTE a reportable condition and delegated surveillance-related responsibilities to the University of Oklahoma, College of Public Health. The surveillance system included active and passive methods. Active surveillance involved reviewing imaging studies (such as chest computed tomography and compression ultrasounds) from all inpatient and outpatient facilities. Interrater agreement between surveillance officers collecting data was assessed using κ. Passive surveillance used International Classification of Disease, Ninth Revision (ICD-9) codes from hospital discharge data to identify cases. The sensitivity and specificity of various ICD-9-based case definitions will be assessed by comparison with cases identified through active surveillance. As of February 1, 2015, we screened 54,451 (99.6%) of the imaging studies and identified 2,690 case patients, of which 91.5% were from inpatient facilities, and 8.5% were from outpatient facilities. Agreement between surveillance officers was high (κ ≥0.61 for 93.2% of variables). Agreement for the diagnosis of pulmonary embolism and diagnosis of deep vein thrombosis was κ = 0.92 (95% CI 0.74-1.00) and κ = 0.89 (95% CI 0.71-1.00), respectively. This surveillance system will provide data on the accuracy of ICD-9-based case definitions for surveillance of VTE events and help the Centers for Disease Control and Prevention develop a national VTE surveillance system.

INTRODUCTION: The objective of this study was to examine the differences in commonly associated characteristics and risk factors of venous thromboembolism (VTE) between patients with and without cancer in a VTE population. MATERIALS AND METHODS: Uniform data were collected for patients with a diagnosis of VTE obtaining care at CDC funded Thrombosis Network Centers. Patient characteristics and risk factors were compared in VTE patients with and without cancer. Logistic regression was used to calculate the unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) to assess patient characteristics and thrombotic risk factors more frequently identified among VTE patients with cancer compared to those without cancer. RESULTS: Between August 2003 and April 2011, 3,115 adult patients with a diagnosis of VTE including 189 (6.1%) patients with active cancer participated in the multi-site thrombosis registry. VTE patients with cancer had a higher prevalence of PE and DVT in unusual sites compared to those without cancer. Thrombophilia was more common among VTE patients without cancer than those with cancer (25.1% vs 10.6%, p<0.001). In adjusted analysis, age group≥45years (OR =5.20, 95% CI, 3.30, 8.18), surgery (OR =1.86, 95% CI, 1.19, 2.91), and hypertension (OR =1.66, 95% CI, 1.15, 2.40) were the VTE risk factors more commonly found among VTE patients with cancer. CONCLUSION: The study identified several thrombotic risk factors more likely to be found with cancer associated VTE, which may help to characterize at risk cancer patients and to develop prevention and management strategies in this population.

BACKGROUND: Venous thromboembolism (VTE) is a significant clinical and public health concern. We evaluated a variety of multilevel factors-demographics, clinical and insurance status, preexisting comorbid conditions, and hospital characteristics-for VTE diagnosis among hospitalizations of US adults. METHODS: We generated adjusted odds ratios with 95% confidence intervals (CIs) and determined sources of outcome variation by conducting multilevel logistic regression analysis of data from the 2011 Nationwide Inpatient Sample that included 6,710,066 hospitalizations of US adults nested within 1,039 hospitals. RESULTS: Among hospitalizations of adults, age, sex, race or ethnicity, total days of hospital stay, status of health insurance, and operating room procedure were important determinants of VTE diagnosis; each of the following preexisting comorbid conditions-acquired immune deficiency syndrome, anemia, arthritis, congestive heart failure, coagulopathy, hypertension, lymphoma, metastatic cancer, other neurological disorders, obesity, paralysis, pulmonary circulation disorders, renal failure, solid tumor without metastasis, and weight loss-was associated independently with 1.04 (95% CI: 1.02-1.06) to 2.91 (95% CI: 2.81-3.00) times increased likelihood of VTE diagnosis than among hospitalizations of adults without any of these corresponding conditions. The presence of 2 or more of such conditions was associated a 180%-450% increased likelihood of a VTE diagnosis. Hospitalizations of adults who were treated in urban hospitals were associated with a 14%-15% increased likelihood of having a VTE diagnosis than those treated in rural hospitals. Approximately 7.4% of the total variation in VTE diagnosis occurred between hospitals. CONCLUSION: The presence of certain comorbidities and hospital contextual factors is associated with significantly elevated likelihood of VTE diagnosis among hospitalizations of adults. The findings of this study underscore the importance of clinical risk assessment and adherence to evidence-based clinical practice guidelines in preventing VTE, as well as the need to evaluate potential contextual factors that might modify the risk of VTE among hospitalized patients.

INTRODUCTION: Recurrent venous thromboembolism (VTE) occurs infrequently following a provoked event but occurs in up to 30% of individuals following an initial unprovoked event. There is limited understanding of the biological mechanisms that predispose patients to recurrent VTE. OBJECTIVES: To identify whole blood gene expression profiles that distinguished patients with clinically distinct patterns of VTE. PATIENTS/METHODS: We studied 107 patients with VTE separated into 3 groups: (1) 'low-risk' patients had one or more provoked VTE; (2) 'moderate-risk' patients had a single unprovoked VTE; (3) 'high-risk' patients had ≥2 unprovoked VTE. Each patient group was also compared to twenty-five individuals with no personal history of VTE. Total RNA from whole blood was isolated and hybridized to Illumina HT-12V4 Beadchips to assay whole genome expression. RESULTS: Using class prediction analysis, we distinguished high-risk patients from low-risk patients and healthy controls with good receiver operating curve characteristics (AUC=0.81 and 0.84, respectively). We also distinguished moderate-risk individuals and low-risk individuals from healthy controls with AUC's of 0.69 and 0.80, respectively. Using differential expression analysis, we identified several genes previously implicated in thrombotic disorders by genetic analyses, including SELP, KLKB1, ANXA5, and CD46. Protein levels for several of the identified genes were not significantly different between the different groups. CONCLUSION: Gene expression profiles are capable of distinguishing patients with different clinical presentations of VTE, and genes relevant to VTE risk are frequently differentially expressed in these comparisons.

Nonmalignant blood disorders currently affect millions of Americans, and their prevalence is expected to grow over the next several decades. This is owing to improvements in treatment leading to increased life expectancy of people with hereditary conditions, like sickle cell disease and hemophilia, but also the rising occurrence of risk factors for venous thromboembolism. The lack of adequate surveillance systems to monitor these conditions and their associated health indicators is a significant barrier to successfully assess, inform, and measure prevention efforts and progress toward national health goals. CDC is strengthening surveillance activities for blood disorders by improving and developing new methods that are tailored to best capture and monitor the epidemiologic characteristics unique to each disorder. These activities will provide a robust evidence base for public health action to improve the health of patients affected by or at risk for these disorders.

Previous research has suggested autoimmune diseases are risk factors for developing venous thromboembolism (VTE). We assessed whether having diagnoses of selected autoimmune diseases associated with antiphospholipid antibodies-autoimmune hemolytic anemia (AIHA), immune thrombocytopenic purpura (ITP), rheumatoid arthritis (RA), and systemic lupus erythematosus (SLE)-were associated with having a VTE diagnosis among US adult hospitalizations. A cross-sectional study was conducted using the 2010 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. VTE and autoimmune diseases were identified using International Classification of Diseases, Ninth Revision, Clinical Modification coded diagnoses information. The percentages of hospitalizations with a VTE diagnosis among all non-maternal adult hospitalizations without any of the four autoimmune diseases of interest and among those with AIHA, ITP, RA, and SLE diagnoses were 2.28, 4.46, 3.35, 2.65 and 2.77 %, respectively. The adjusted odds ratios (OR) for having a diagnosis of VTE among non-maternal adult hospitalizations with diagnoses of AIHA, ITP, RA, and SLE were 1.25 [95 % confidence interval (CI) 1.05-1.49], 1.20 (95 % CI 1.07-1.34), 1.17 (95 % CI 1.13-1.21), and 1.23 (95 % CI 1.15-1.32), respectively, when compared to those without the corresponding conditions. The adjusted OR for a diagnosis of VTE associated with a diagnosis of any of the four autoimmune diseases was 1.20 (95 % CI 1.16-1.24). The presence of a diagnosis of AIHA, ITP, RA, and SLE was associated with an increased likelihood of having a VTE diagnosis among the group of all non-maternal adult hospitalizations.

INTRODUCTION: Black women have an increased risk of adverse pregnancy outcomes and the characteristics of thrombotic risk factors in this population are unknown. The objective of this study was to examine the racial differences in thrombotic risk factors among women with adverse pregnancy outcomes. METHODS: Uniform data were collected in women with adverse pregnancy outcomes (pregnancy losses, intrauterine growth restriction (IUGR), prematurity, placental abruption and preeclampsia) referred to Thrombosis Network Centers funded by the Centers for Disease Control and Prevention (CDC). RESULTS: Among 343 white and 66 black women seen for adverse pregnancy outcomes, protein S and antithrombin deficiencies were more common in black women. The prevalence of diagnosed thrombophilia was higher among whites compared to blacks largely due to Factor V Leiden mutation. The prevalence of a personal history of venous thromboembolism (VTE) did not differ significantly by race. A family history of VTE, thrombophilia, and stroke or myocardial infarction (MI) was higher among whites. Black women had a higher body mass index, and a higher prevalence of hypertension, while the prevalence of sickle cell disease was approximately 27 fold higher compared to the general US black population. CONCLUSIONS: Thrombotic risk factors differ significantly in white and black women with adverse pregnancy outcomes. Such differences highlight the importance of considering race separately when assessing thrombotic risk factors for adverse pregnancy outcomes.

BACKGROUND: Emergence of the novel 2009 influenza A H1N1 virus in California led to an evaluation of hospital respiratory protection programs (RPPs) and practices by the California Department of Public Health during the 2009-2010 influenza season. METHODS: Onsite evaluation of 16 hospitals consisted of interviews with managers and health care workers about RPPs and practices, review of written RPPs, and limited observations of personnel using respirators. Data were analyzed using descriptive statistics. RESULTS: All hospitals had implemented policies requiring the minimum use of N95 filtering facepiece respirators when working with patients with H1N1 virus infection; 95.5% of health care workers (n = 199) reported they would wear at least this level of protection when in close contact with a patient with confirmed or suspected H1N1 virus infection. However, evaluation of written RPPs indicated deficiencies in required areas, most commonly in recordkeeping, designation of a program administrator, program evaluation, employee training, and fit testing procedures. CONCLUSIONS: Health care workers were aware of respiratory protection required when providing care for patients with confirmed or suspected H1N1 virus infection. Hospitals should improve written RPPs, fully implement written procedures, and conduct periodic program evaluation to ensure effectiveness of respirator use for health care worker protection. Increased accessibility of resources tailored for hospital respirator program administrators may be helpful.

BACKGROUND: Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is a significant source of mortality and morbidity worldwide. By analyzing data of the 2010 Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality (AHRQ), we evaluated the predictive accuracy of the AHRQ's 29-comorbidity index with in-hospital death among US adult hospitalizations with a diagnosis of VTE. METHODS: We assessed the case-fatality and prevalence of comorbidities among a sample of 153,518 adult hospitalizations with a diagnosis of VTE that comprised 87,605 DVTs and 65,913 PEs (with and without DVT). We estimated adjusted odds ratios and 95% confidence intervals with multivariable logistic regression models by using comorbidities as predictors and status of in-hospital death as an outcome variable. We assessed the c-statistics for the predictive accuracy of the logistic regression models. RESULTS: In 2010, approximately 41,944 in-hospital deaths (20,212 with DVT and 21,732 with PE) occurred among 770,137 hospitalizations with a diagnosis of VTE. When compared separately to hospitalizations with VTE, DVT, or PE that had no corresponding comorbidities, congestive heart failure, chronic pulmonary disease, coagulopathy, liver disease, lymphoma, fluid and electrolyte disorders, metastatic cancer, other neurological disorders, peripheral vascular disorders, pulmonary circulation disorders, renal failure, solid tumor without metastasis, and weight loss were positively and independently associated with 10%-125% increased likelihoods of in-hospital death. The c-statistic values ranged from 0.776 to 0.802. CONCLUSION: The results of this study indicated that comorbidity was associated independently with risk of death among hospitalizations with VTE and among hospitalizations with DVT or PE. The AHRQ 29-comorbidity index provides acceptable to excellent predictive accuracy for in-hospital deaths among adult hospitalizations with VTE and among those with DVT or PE.

BACKGROUND: Excluding disinfectants, pyrethrins and pyrethroids are the pesticides used most commonly in and around homes. Respiratory effects and paresthesia are among the concerns about pyrethrin/pyrethroid exposures. METHODS: Acute pesticide-related illness/injury cases were identified from the Sentinel Event Notification System for Occupational Risks-Pesticides Program and the California Department of Pesticide Regulation from 2000-2008. Characteristics and incidence rates were determined for acute pyrethrin/pyrethroid-related illness/injury cases. Logistic regression analyses were performed to determine odds of respiratory and dermal symptoms in persons with illness/injury following pyrethrin/pyrethroid exposure compared to persons with illness/injury following exposure to other pesticides. RESULTS: A total of 4,974 cases of acute pyrethrin/pyrethroid-related illness were identified. Incidence rates increased over time, reaching 8 cases/million population in 2008. The majority of cases were low severity (85%) and 34% were work-related. Respiratory effects were the most common symptoms reported (48%). Risk of acute respiratory effects were significantly elevated among persons exposed only to pyrethrins (adjusted odds ratio [aOR] 1.79; 95% confidence interval [95% CI]: 1.49-2.16), only to pyrethroids (aOR 1.99 95% CI: 1.77-2.24), to a mixture of pyrethroids (aOR 2.36; 95% CI: 1.99-2.81) or to a mixture containing both pyrethrins and pyrethroids (aOR 2.99; 95% CI: 2.33-3.84) compared to those with illness arising from exposure to other pesticides. The most common factors contributing to pyrethrin/pyrethroid-related illness included exposure from spills/splashes, improper storage, and failure to evacuate during pesticide application. CONCLUSIONS: The magnitude of acute pyrethrin/pyrethroid-related illness/injury is relatively low but is increasing. As such, additional measures to prevent them are needed.

BACKGROUND: Farmworkers have a high risk for acute pesticide-related illness and injury, and the rate among female farmworkers is approximately twice as high as that among males. Surveillance data were used to identify reasons for this gender difference. METHODS: We identified acute pesticide-related illness and injury cases among farmworkers from the Sentinel Event Notification System for Occupational Risks (SENSOR)-Pesticides Program and the California Department of Pesticide Regulation. Gender-specific associations with acute pesticide-related illness and injury were assessed using chi-square tests. National Agricultural Workers Survey data were also examined. RESULTS: The over-representation of females among farmworker illness and injury cases was confined to females who did not handle pesticides (non-handlers). Female non-handler farmworkers who were affected were more likely to be working on fruit and nut crops, to be exposed to off-target pesticide drift, and to be exposed to fungicides and fumigants compared to males. CONCLUSIONS: Although there is an increased risk for acute pesticide-related illness and injury among female farmworkers, the absolute number of farmworkers with acute pesticide-related illness and injury is far higher among males than females. Furthermore, farmworkers have little or no control over many of the identified contributing factors that led to illness and injury. Stringent enforcement of existing regulations and enhanced regulatory efforts to protect against off-target drift exposures may have the highest impact in reducing acute pesticide-related illness and injury among farmworkers. (Am. J. Ind. Med. Published 2012. This article is a U.S. Government work and is in the public domain in the USA.)

Obesity, a health concern of increasing importance in developed countries, is associated with a four- to five-fold increased risk of venous thromboembolism (VTE) in pregnancy [1], [2]. In one study, obese pregnant women were three times more likely to suffer a pulmonary embolism (PE) than a deep vein thrombosis (DVT), placing them at greater risk for mortality than non-obese gravidas [2]. Obesity is also associated with poor pregnancy outcomes, including a 40 percent increased risk for stillbirth compared to non-obese gravidas [3]. | A respectable body of literature has documented many of the changes in clotting and fibrinolysis during normal pregnancy, but little has been reported on the effect of obesity on these processes [4], [5], [6], [7], [8]. We hypothesize that the increased risk of VTE in pregnancy associated with obesity, while likely multifactorial, is partly explained by changes in coagulation proteins. We compared clotting factor levels in obese and non-obese pregnant women with the purpose of identifying specific changes in obese gravidas that might place them at higher risk for VTE than non-obese gravidas.